Patient information

Save time at your first visit.

Please download and complete your new patient forms, then bring the completed pages with you to your first office visit. Prefer to type? Fill them out online below and print your completed copy.

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Complete these three forms by hand and bring them with you to your first visit.

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Jantz Family Practice
706 Cadet Court, Lebanon, TN 37087  ·  P: 615-449-2472   F: 615-449-4709
Robert J. Jantz, M.D.  ·  Caroline Hendrick FNP-C  ·  Nathan Marks FNP-C
Updated 7/1/24Page 1 of 5

Patient Demographics

Name (First Middle Last):
Date of Birth:    SS#:
Address:
City:   State:   Zip:
Phone:   Cell:   Work:
Email:
Contact me for appointments and test results via:   {{ o.label }}
May we leave a message on your voicemail?   {{ o.label }}
Patient's Employer:   Phone:
Insured's Name:   Date of Birth:
Insured's Employer:   Phone:
Which Pharmacy do you prefer and its location?
What type of insurance do you have?
ID #   Group #

Please give insurance card and photo ID to receptionist upon arrival at each visit.

I hereby authorize direct payment of medical/surgical benefits to Jantz Family Practice for services rendered in person or under their supervision by my insurance carrier. I agree to be financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I understand that I am also responsible for all collection and/or attorney fees should my account be turned over for collection.

Nothing entered on this page is saved or transmitted until you print the completed form.

Patient Signature Today’s Date
Guardian/ Legal Rep (if minor)
Signature of Guardian
Jantz Family Practice
Robert J. Jantz, M.D.  ·  Caroline Hendrick FNP-C  ·  Nathan Marks FNP-C
Updated 7/1/24Page 2 of 5

Release of Health Information

CONSENT AND AUTHORIZATION TO RELEASE INFORMATION OR HEALTH RECORDS UNDER THE PROTECTION OF FEDERAL LAW, TITLE 42, CFR CHAPTER 11 PART 11

Name:   Date of Birth:
SS#:   Sex:

I Authorize (Name, Address, and Phone Number) to release my health records or information concerning my health records to Jantz Family Practice, 706 Cadet Court Lebanon, TN 37087. Phone 615-449-2472 Fax 615-449-4709.

I specifically consent only to the release of information or health records pertaining to:

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Other (specify):

I understand that I may revoke this consent to release of information at any time; however, I also understand that any release which has been made prior to my revocation and which was made in issuance upon this authorization shall not constitute breach of my right to confidentiality. Unless I revoke this authorization prior to such time, this authorization to release information shall expire when records are received or 1 year after the date of signature. At this time, no express revocation shall be needed to terminate my consent: however, revocation consent at any other time must be provided in writing.

Patient's signature Date
Witness Signature Date
Jantz Family Practice
Robert J. Jantz, M.D.  ·  Caroline Hendrick FNP-C  ·  Nathan Marks FNP-C
Updated 7/1/24Page 3 of 5

Notice of Privacy Practices Acknowledgement

Name:   Date of Birth:

I have received a copy of the NOTICE OF PRIVACY PRACTICES. I understand that Jantz Family Practice has the right to change the PRIVACY PRACTICES from time to time and that I may contact the office at any time to obtain a current copy of the NOTICE OF PRIVACY PRACTICES.

Do you have a living will?   {{ o.label }}   Date it was it last updated?
Emergency Contact:   Phone:

Who may receive information regarding your Protected Health Information? (Test Results / Appointments / Balances / Account Information)

Name:
Check One: {{ o.label }}
Name:
Check One: {{ o.label }}
Name:
Check One: {{ o.label }}

Nothing entered on this page is saved or transmitted until you print the completed form.

Patient Signature Date
Guardian/ Legal Rep (if minor)
Signature of Guardian
Jantz Family Practice
Robert J. Jantz, M.D.  ·  Caroline Hendrick FNP-C  ·  Nathan Marks FNP-C
Updated 7/1/24Page 4 of 5
Patient Name:   Date of Birth:
Patient Medical History
(Please check all that apply to your health history)
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Other:
Patient Surgical History
(Please check all that apply to your health history)
{{ sg.label }} Date
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Other Surgery Date
Please list any other hospitalizations
Reason:   Date:
Family Medical History
(Please check any that apply - note relationship to you, whether deceased, and age at death)
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Relationship Deceased? {{ dopt.label }} Age at death
Jantz Family Practice
Robert J. Jantz, M.D.  ·  Caroline Hendrick FNP-C  ·  Nathan Marks FNP-C
Updated 7/1/24Page 5 of 5
Patient Name:   Date of Birth:
Patient Allergies
(Please list any allergies to medications below)
Patient Medications
Please list any Prescription or Over the Counter medications below (Medication Name, Strength, Dose)
Social History / Habits
Tobacco:  {{ o.label }}
Amount per day   # of Years   Have you quit? {{ o.label }}
Alcoholic Beverages: {{ o.label }}
Type   Amount
Coffee/Caffeine Cups/Glasses per Day
Exercise: {{ o.label }}
Type   Times per week

Sign & print

Signature (type your full name) Date
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We are now accepting new patients.

Please call our office to verify if we are accepting your insurance and to schedule a new patient visit.

Call (615) 449-2472